SURGICAL INSTRUMENTATION : USE , C ARE AND HANDLING

1958 1958 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING

STUDY GUIDE

Disclaimer AORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products or services. Although all commercial products in this course are expected to conform to professional medical/nursing standards, inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or of the claims made by the manufacturers. No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independent verification of diagnoses, medication dosages, and individualized care and treatment should be made. The material contained herein is not intended to be a substitute for the exercise of professional medical or nursing judgment. The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN, INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE. This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The following credit line must appear on the front page of the photocopied document:

Reprinted with permission from The Association of periOperative Registered Nurses, Inc. Copyright 2012 “Surgical Instrumentation: Use, Care, and Handling.”

All rights reserved by AORN, Inc. 2170 South Parker Road, Suite 400, Denver, CO 80231-5711 (800) 755-2676 www.aorn.org Video produced by Cine-Med, Inc. 127 Main Street North, Woodbury, CT 06798 Tel (203) 263-0006 Fax (203) 263-4839 www.cine-med.com

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Surgical Instrumentation: Use, Care and Handling

TABLE OF CONTENTS

PURPOSE/GOAL /OBJECTIVES ...... 4 INTRODUCTION ...... 5 MANUFACTURING PROCESSES ...... 5 ...... 5 Titanium ...... 5 Vitallium ...... 5 Other Metals ...... 5 Instrument names ...... 6 TYPES OF SURGICAL INSTRUMENTS ...... 6 Cutting and Dissecting Instruments ...... 6 Powered Cutting Instruments ...... 8 Clamping and occluding instruments ...... 8 Grasping and Holding Instruments ...... 10 Exposing and Retracting Instruments ...... 10 Suturing and stapling instruments ...... 11 Accessory Instruments ...... 12 ENDOSCOPIC (MINIMALLY INVASIVE) INSTRUMENTS ...... 13 INSTRUMENT CARE AND HANDLING ON THE STERILE FIELD ...... 14 INSTRUMENT CARE AFTER PROCEDURE ...... 15 Decontamination ...... 15 Cleaning ...... 15 Inspecting ...... 16 Endoscope Cleaning ...... 16 Laparoscopic Instruments ...... 16 Powered Surgical Instruments ...... 18 SPECIAL PRECAUTIONS ...... 19 Ophthalmic Instruments ...... Prion Diseases ...... PERSONAL PROTECTIVE EQUIPMENT (PPE) ...... 19 SUMMARY ...... 19 REFERENCES ...... 20 POST-TEST ...... 21 POST-TEST ANSWERS ...... 24

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PURPOSE/GOAL The purpose of this study guide and accompanying video is to provide information to perioperative staff members on the use, care and handling of all surgical instruments including minimally invasive, powered and endoscopic instruments.

OBJECTIVES After viewing the video and completing the study guide, the participant will be able to: 1) State the principles of instrument care. 2) Describe the four major categories of surgical instruments. 3) Name the basic components of powered instruments. 4) Discuss special considerations for endoscopic instruments. 5) Discuss intraoperative instrument handling including proper passing techniques. 6) Describe the proper cleaning required for each category of instrument.

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INTRODUCTION instruments produced. It is important for perioperative staff Surgical instruments are members to know what each instrument is made of. The metal high quality tools that are alloys used in surgical instruments must be resistant to designed for accomplishing corrosion, which can result from exposure to blood, body a specific desired effect fluids, cleaning solutions, sterilization, and the atmosphere. during invasive procedures. Instruments are integral Stainless Steel components of all surgical Instruments made of stainless steel begin the manufacturing procedures. Perioperative staff members must understand the process with the conversion of raw steel into instrument use, handling, and care of surgical instruments. Proper blanks. There are more than 80 different types of stainless steel cleaning and handling minimizes damage, increases and these are graded based on quality and composition. The instrument life expectancy, and protects instruments, which most common grades used for surgical instruments are the 300 are a major financial investment for facilities. Careful and 400 series grades and of those, the 400 series is more planning, preparation, and use of instruments will contribute commonly used. Instruments such as retractors and speculums to an efficient and effective surgical procedure within a safe are generally manufactured from the 300 series, while cutting environment. and non-cutting instruments are made from the 400 series. Surgical instruments perform basic functions such as holding Titanium or retracting tissue; dissecting, cutting, or incising tissue; and Titanium has excellent metallurgical properties for use in assisting with suturing and or closure of the surgical incision. microsurgical instruments. The most notable and useful Most surgical instruments are made of stainless steel or other properties of titanium are that it is nonmagnetic and inert. It metals. The metal selected must be easily cleaned, disinfected, is harder, stronger, lighter in weight, and more resistant to and maintained. corrosion than stainless steel. 1

Surgical procedures are becoming more complicated and Vitallium intricate and as a result surgical instruments are becoming Vitallium, the trade name for a cobalt/chromium/molybdenum more complex, more precise in design, and more delicate in alloy, is suitable for orthopedic devices and maxillofacial structure. With the development of new tools, instrument care implants because of its strength and corrosion-resistant and handling becomes more challenging. There are currently properties. Vitallium instruments must be used with vitallium hundreds of different types of surgical instruments and more implants to maintain electrolytic compatibility. 1 are being developed everyday as surgical procedures change and evolve. Other Metals While most instruments are made of steel alloys, some are MANUFACTURING PROCESSES made from brass, silver, or aluminum. Some cutting blades, tips, and jaws are laminated with tungsten carbide, which is an exceptionally hardened metal. 1 The cutting or drilling of instrument blanks is accomplished by different methods, one of which is the precision blasting of the instrument blank sheath with garnet sand while it is submerged in a bath of bubbling coolant. The cut needed is programmed into a computer that directs the cutting arm of Surgical instruments are the surgeon’s tools. Each one is the machine. The measurements are precise, sometimes within designed and carefully crafted for an intended surgical a fraction of an inch, to make sure the component parts fit and purpose. They must be durable and not prone to rusting, meet in the exact manner needed. The machines designed to chipping, or denting with normal handling, which is why most produce surgical instruments meticulously follow the are made with stainless steel, a combination of carbon, computerized engineering designs and warn the operator if chromium, iron, and a few other alloys (i.e., metals). With errors occur during drilling and cutting. When this process is advances in modern technology, other materials such as complete, the raw steel material has become an instrument titanium and vitallium, and other polymers are also used, but that is designed to do a particular job and function in a stainless steel continues to account for the majority of particular manner.

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Th e next step in the manufacturing process is providing happening on the surgical field and knowing this progression corrosion resistance. This is accomplished by the removal of will help the scrub person to anticipate which instrument will carbon steel particles through immersion of the instrument into be needed. diluted nitric acid. The final step is to polish the instr ument. • An incision is made using a cutting instrument, such Manufacturers of surgical instruments add one of three as a knife or . Clamps or may be used finishes during fabrication: satin (i.e., dull), highly polished, to control superficial bleeding at this point. and ebonized. Electrosurgical energy delivered through an active electrode may be used to create hemostasis or to • A highly-polished finish, increases resistance to extend the excision. corrosion, but can affect the ability of the surgeon to see because of light reflection. • Cutting of internal tissue layers is accomplished with scissors. • A satin finish is less reflective and reduces glare. • Exposure of the surgical field is made possible by • An ebonized finish is black chromium, is retractors. nonreflective, and virtually eliminates glare. • evacuation is used to eliminate the surgical For most procedures, either satin or highly-polished smoke plume created by the electrosurgical unit and instruments will be used. Ebonized instruments are typically to suction fluid or blood from the surgical field. used in laser procedures to prevent laser beam reflection off the instrument. It is easy to see that surgical instruments can be classified into four main categories: Instrument Names • cutting and dissecting, Surgical nomenclature lacks standardization, but will generally follow certain patterns. For example, instruments • clamping, may be named: • grasping or holding, and • by the action that the instrument is designed to • exposing and retracting. perform (e.g., scissors, knife), A fifth category exists for other accessory instruments that do • to recognize the inventor (e.g., ), or not easily fit into these main classifications. These will be discussed later in this study guide. • a combination of how the instrument is to perform in a particular type of and an inventor’s name Cutting and Dissecting Instruments (e.g., a Lambotte , a tool that is designed to Basic cutting and dissecting cut bone, invented by Lambotte). instruments, sometimes Names of instruments also vary by the region of the country referred to as “sharps,” do in which they are used, the surgeon’s preference for a name, exactly what their name and the facility’s commonly used name. implies; they cut and dissect tissue or other Because instruments represent a major financial investment materials. The useable part for a facility, proper care and handling should be a primary of the instrument has a concern for all personnel who work with instruments. After sharp or cutting edge. Cutting instruments include knives, instruments are received from the supplier, they should be , and scissors of all types and shapes. carefully examined, cleaned, decontaminated, and sterilized according to the manufacturer’s instructions before use in the Knives and scalpels sterile field. The words knife and are used interchangeably, but generally, a scalpel has a detachable, disposable blade and TYPES OF SURGICAL INSTRUMENTS nondisposable handle, while the term knife refers to single- Many different kinds of surgical instruments and tools have unit cutting device such as an amputation knife. The handle been invented over the years. Instruments may be designed size and configuration of scalpel handles varies to for general surgical use or for use during a specific procedure. accommodate the area of use. Knife blades may have curved Generally, there is a natural progression of instrument use edges or sharp, stabbing points. When using a knife, care must during a surgical procedure. Paying close attention to what is be taken to avoid injury to self or others.

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Passing Knives and Scalpels meet at the swivel (i.e., the point where the rivet or screw connects the blades) and the cutting point. The blades of the scissors also must be sharp. Cutting anything other than what the scissors were designed to cut (i.e., using tissue scissors to cut suture) will dull the blades and result in their misalignment. Routinely check to ensure that the blades are sharp and that the screw joining them together has not loosened. This can be accomplished by holding the scissors horizontally by one ring handle. If the blades open freely, the scissors need to be tightened. The two basic types of scissors When required to pass a sharp item to the surgeon, AORN’s are: tissue and suture scissors. Guidance Statement: Sharps Injury Prevention in the Perioperative Setting calls for the use of a “neutral or hands- Tissue Scissors free technique whenever possible or practical instead of Tissue scissors are used for tissue dissection. Most tissue 2 passing hand to hand.” A neutral zone is a designated area on scissors have curved tapered points. are the sterile field where the scrub person and the surgeon place used to cut medium to delicate tissue while the sturdier Mayo all sharp instruments (including needles). If it is absolutely scissors are used to cut necessary to pass a knife hand-to-hand, it should be held heavy or thicker tissue or carefully between thumb and fingers and presented handle structures such as fascia. A first to the surgeon with the cutting edge of the blade pointing Metzenbaum scissors can down and away from both of you. be distinguished from the Caution must be taken when loading or removing blades from by its narrow a knife handle. Typically, an instrument such as a needle shaft and tips. holder or is used to hold the blade during removal. The curvature on the Metzenbaum and other tissue scissors is Many health care facilities provide disposable scalpels for use desirable to surgeons because it facilitates the ability to see as a way to reduce the risk of injury and exposure to blood- the tips of the scissors during dissection and because they can borne pathogens. reach around other structures. Small, fine scissors with sharp tips (e.g., , Castroviejo scissors), are used for Scissors delicate ophthalmic or reconstructive surgery. Scissors are designed in short, medium, long, and Suture Scissors heavy lengths and may be Suture scissors usually have straight blades and blunt points. blunt or sharp with straight Straight Mayo scissors are used primarily to cut suture. or curved tips on their Angled can be used to cut bandages and cutting edges. Scissors dressings. Wire scissors should be used to cut wire and very consist of a pair of metal blades connected in such a way that heavy sutures. the edges of the blades cut materials placed between them when the handles are brought together. A conventional Passing scissors scissors requires one movement to open the jaws and another to close them. Some scissors, particularly those used in delicate plastic and eye surgery, have a spring that holds the jaws open. Squeezing the handle together closes the blades and relaxing of the grip opens them. When preparing for a surgical procedure, it is important to check the To pass any curved instrument, including scissors, hold the alignment of the scissors instrument at the joint and place the handle of the instrument blades. For scissors to cut firmly in the surgeon’s hand, in its position of use. The tips of smoothly, the blades must

7 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING the instrument should always be visible. Curved tips should Powered Cutting Instruments point down. Gently snap or flip the wrist when placing the Powered cutting instruments instrument in the surgeon’s hand so the surgeon knows where are precision devices the instrument is. This eliminates the need for the surgeon to designed to make working stop and look for the instrument. Release the instrument as with bone and cartilage easier soon as the surgeon has a firm grip on it. and quicker than working by hand. They are used most Other Cutting and Dissecting Instruments often for precision drilling, Other specialized cutting instruments include chisels, , cutting, shaping, and beveling , rasps, rongeurs, saws, and trephines. bone. There are many interchangeable attachments available • Chisels are used to sculpt bone and have one beveled for powered surgical hand pieces, and they are used in a wide edge. A mallet is used in conjunction with a chisel. variety of procedures. Some uses include: • Curettes are used to scrape soft tissue or bone. They • Drilling holes for placement of a metal plate to hold a are manufactured with different size cupped ends and fracture together. This requires points, screws, several angles and lengths. Uterine curettes are used and a screwdriver. to scrape the endometrial lining of the uterus. • Removing, reshaping, and reaming of bone at the knee • Osteotomes are bone-cutting instruments used for or hip joint for placement of a total joint prosthesis. shaping or marking bone. They have a double, beveled This requires saw blades and drill bits of various sizes edge and come in several widths and are both curved and shapes. Both forward and reverse speeds are and straight in design. They may be used to remove necessary for some of these activities. periosteum from bone. A mallet is used in conjunction The first powered surgical instruments were powered by with an osteotome. electricity, air, or nitrogen under pressure stored in large • Rasps can be used to smooth rough bone surfaces or portable tanks. The electrically powered instruments were to evacuate the medullary canal in preparation for difficult to maintain because the electrical cords deteriorated insertion of an orthopedic prosthesis. They may be rapidly due to processing. For pneumatic instruments, a single- or double-ended, with curved or tapered pressure gauge controls the flow at a specified pounds per blades. Rasps may be forward- or backward- cutting, square inch (PSI) pressure. Alternatively, compressed gas can with fine or coarse teeth. be piped directly into the operating suite. In this type of • Rongeurs are biting instruments used for cutting system, a wall unit acts as the pressure gauge and controls the tough tissue or bone. The biting cup comes in various flow of gas, delivering a specific PSI. Special high-power sizes and angles. When the surgeon squeezes the hoses connect the gas source to the handpiece of the handles together, the two sharp, cup-like ends come instrument. Surgeons found these pneumatic hoses unwieldy together to bite into the tissue and remove a small which promoted the development of battery-operated surgical section. Rongeurs are most commonly used on bones instruments, that have now become commonplace. After use, the battery pack is recharged and is sterilized immediately or heavy ligaments. They may be double- or single- 3 action. before the powered instrument is used. • Saws include any notched blade used for cutting bone. Clamping and Occluding Instruments • Trephines are used to cut bone from the skull. A Surgical clamps can be used to either compress or grasp a trephine has a circular, sharpened edge. structure. They can be either occluding or nonoccluding (also referred to as crushing or non-crushing). The types of clamps needed for a particular procedure will depend on the kind of tissue to be held (i.e., delicate or tough) and the depth of the surgical procedure (i.e., near the surface or deep). and occluding clamps should never be used to attach items to the surgical drapes because this could bend their tips and strain the box lock, making the instrument unsafe to use on tissue.

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Hemostats • Allis clamps also allow grasping and holding without Hemostats are the most crushing. They have multiple, tiny, fine teeth that common of all clamping curve slightly inward. Allis clamps will hold slightly instruments. They are used heavier tissue than Babcock clamps because they have to grasp bleeding vessels serrations along their edges. and prevent blood loss with • Kocher clamps are easily identified by the transverse minimal tissue damage. serrations and the large teeth at the tips. This enables Hemostats range in size the surgeon to grasp and tightly hold heavy, tough, or from short to long and from slippery tissue such as fascia, bone, and cartilage. The delicate to heavier in design. They can be straight or curved. Kocher is also known as an Ochsner clamp. Examples of hemostats are the mosquito, Kelly, and Crile. Other types of clamps include hemostatic clips that may be • Mosquito clamps are used to control surface bleeders loaded singly onto an applier or may come as a preloaded, and handle delicate tissue (e.g., plastic surgery hand disposable unit. These clips come in multiple sizes and the surgery); clip appliers are available in long and short lengths. These will • Kelly clamps are used to control bleeders in muscle be covered in more detail under “Suturing and Stapling tissue, to pass drains, and to hold Kitner or peanut Instruments.” sponges; and, A general rule of thumb for selecting a clamp is to use delicate • Crile clamps are used to control bleeders in clamps for delicate tissue, heavy clamps for heavier or tougher subcutaneous tissue. tissue. This concept can also be applied to the depth of the Perhaps the most important design feature of a is the surgical procedure; shorter clamps for superficial areas, longer jaw portion between the box lock and the tip. Some hemostats clamps when working deep within a cavity. Another concept are very slender and tapered to a fine point; others are thicker, to note is that finer clamps should be used on smaller vessels with more blunt tips. The inside surfaces have deep grooves and heavier clamps on thicker structures. or serrations, which may go from side to side or run longitudinally in the same direction as the jaws. These Anatomy of a clamp serrations allow bleeding vessels to be compressed with sufficient force to stop bleeding. The serrations must be cleanly cut and perfectly meshed to prevent the tissue from slipping free from the ends of the clamp.

Occluding clamps Occluding clamps are used to occlude or constrict tissue and to clamp or grasp bowel, ducts, and other structures with lumens. These instruments are used to apply pressure. They The two parts of a clamp fit together at a box lock which, typically have vertical serrations or special jaws with finely when closed or clamped together, remains locked until the meshed, multiple rows of longitudinally arranged teeth. They ratchets are released. function to prevent leakage and minimize trauma to vessels The easily identifiable parts of a clamp are: that are to be reanastomosed. Examples of occluding clamps are Babcock, Allis, and Kocher clamps. • The point of the tip which, when closed, should fit tightly together unless it is designed to only partially • Babcock clamps have curved fenestrated tips without compress tissue. teeth. They are used to grip or enclose delicate • The jaws of the instrument are either smooth or are structure such as bowel, appendix, ureters, or fallopian serrated to hold tissue securely. tubes. The smooth edges and bowed shape allow grasping without penetrating, crushing, or • The box lock is the hinge point of the instrument tip traumatizing tissue. and handle.

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• The shank is the area between the box lock and the • Sponge forceps have ring-shaped jaws and are used finger rings. to hold gauze sponges which are then used for • The ratchet is part of the finger ring handle and retraction, blunt dissection, or to absorb blood from interlocks to keep the clamp shut when the instrument the surgical field. Sponge forceps may be straight or is closed. curved. Examples of these are Fletcher sponge forceps and sponge sticks. Passing clamps • Towel forceps are typically used to attach and secure Refer to the preceding section on Passing Scissors. Ensure that draping material but also may be used to hold cartilage the clamp is closed and locked (if applicable). The tips and or scar tissue or to apply traction. They are available curve of the instrument should always be visible. in perforating and nonperforating varieties. GRASPING AND HOLDING INSTRUMENTS • Tenacula have sharp points that are used to penetrate and grasp tissue firmly. An example is a uterine Grasping or holding instruments allow the surgeon to dissect that is used to manipulate the cervix of the and suture tissue without causing injury. Forceps and some uterus. 1 Tenacula may be single- or multitoothed. varieties of clamps are referred to as grasping instruments because of how they perform. Other grasping and holding instruments include stone forceps which are used to grasp calculi (e.g., kidney or gallstones). Forceps , or pickups as they are sometimes called, are two-bladed, Passing forceps tweezer-like instruments that are The scrub person should grasp the top of the instrument where designed to pick up, grasp, and the two arms meet, and with the points down, pass it to the hold tissue to facilitate dissection surgeon allowing the surgeon access to the full length of the or suturing. There are many instrument to adjust his or her grasp. Clamp-type forceps varieties of tips available on should be passed as stated above under Passing Clamps forceps. The selection of forceps depends on the intended use. • Smooth forceps have simple serrations and EXPOSING AND RETRACTING INSTRUMENTS smooth, tapered points for use on delicate tissue. These instruments are used for two major purposes: Examples of smooth forceps include Adson • to hold open the incision to provide exposure of the forceps and Cushing or bayonet forceps. surgical site, and • Toothed forceps may be either single-toothed or • for holding back surrounding organs and tissue to have multiple teeth that interlock. These are facilitate the surgeon’s ability to see during the used on dense structures such as tough skin, procedure. fascia or cartilage when a firm grip is needed. Retractors come in many different sizes and shapes. Retractors They will tear or puncture more delicate tissues. are referred to as either hand-held or self-retaining. Smaller • Atraumatic forceps are used to grasp fine, types can be held by the fingers or hands to retract skin and delicate tissue with minimal trauma. They have subcutaneous tissue in shallow surgical areas while larger, either straight or angled tips and come in heavier types may be self-retaining and are used to retract various lengths and jaw widths. Examples of muscle tissue and organs in deeper surgical sites. atraumatic forceps are DeBakey vascular forceps and bulldog and Cooley forceps. Hand-held Hand-held retractors consist When checking forceps, the perioperative nurse must ensure of a shaft with a curved, that the tips meet correctly and that there are no barbs on the hooked, straight, or angled tips that could cause tissue damage. blade on one or both ends. They usually come in pairs. Other grasping instruments Some examples of hand- Grasping instruments also may be designed like clamps with held retractors are: ring handles. They may have smooth or serrated tips for grasping tissue. • Army-Navy retractors or USA retractors are used in shallow incisions. These double-ended retractors are

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eight inches long and have a different-sized blade at • Balfour retractor – used to retract the abdominal wall each end. during abdominal surgery. The blade on a Balfour is a • Senn retractors – used to maintain exposure in small separate piece of this retractor and is attached and areas, such as in carpal tunnel surgery. These retractors adjusted on the spreader with a wing nut. The spreader are double-ended and have both sharp and blunt can have shallow or deep blades. prongs. • O’Conner-O’Sullivan retractors – also used in • Malleable ribbon retractors – flat metal ribbons that abdominal surgery but more specifically for can be shaped or bent by the surgeon into the needed hysterectomies. This retractor comes in various shape to adequately retract tissue. They can be used configurations with both permanently attached and to protect soft tissue during dissection or to provide adjustable blades. retraction of bowel and soft tissue. Many sizes and • Bookwalter retractors – table mounted and most lengths are available. frequently used in hepatic and thoraco-abdominal • Richardson retractors – frequently used in abdominal procedures. surgery to retract subcutaneous tissue. They come in SUTURING AND STAPLING INSTRUMENTS many sizes and can be used singly or in pairs. • Volkmann retractors – hand-held rake retractors that Needle holders come with two to six sharp or dull prongs. They must Needle holders may look be handled very carefully to prevent injury. They are somewhat like clamps, but used to retract superficial tissue. they are designed specifically to grasp and firmly hold Passing hand-held retractors curved suture needles, not Retractors should be handed to the surgeon handle first, in tissue. Although they position for immediate use. Place the retractor handle gently, resemble hemostats, they but firmly, into the surgeon’s hand. usually have shorter, stubbier jaws. The jaws may be straight, curved, or angled. Most have many small serrations on the Self-retaining retractors insides of the jaws that hold the needle in place during Self-retaining retractors suturing. have holding devices, locks, and catches which Standard needle holders have a longitudinal groove or pit in keep the retractor in a preset the jaw that releases tension, prevents flattening of the needle, position after it is inserted and holds the needle firmly. “Diamond jaw” needle holders and adjusted. Some may be have tungsten carbide inserts that are designed to prevent the clamped in situ or needle from rotating or slipping while passing through tissue. suspended at the end of a Some needle holders have crosshatched serrations that prevent robotic arm or attached to the operating room bed and kept in damage to the needle and some are smooth. The smooth- place by clamps. All pieces of self-retaining retractors with jawed needle holders are used for small needles (e.g., plastic, multiple detachable parts should be checked and accounted eye surgery). 4 for before and after the surgical procedure to reduce the risk Needle holders may have a ratchet similar to that of a of retained surgical items. Examples of self-retaining hemostat, or they may use a locking or non-locking spring retractors include the following. action. Needle holders come in many shapes and sizes to fit • Jansen retractors – frequently used in biopsies, they different needles as well as the procedures to be performed. have two blunt blades held apart by a ratchet with Examples include the following: either 3 or 4 prongs on each side. • Mayo-Hegar needle holders – long and narrow, used • Weitlaner retractors – used to maintain wound to hold medium to heavy-gauge needles to apply exposure during procedures such as inguinal hernia heavy sutures in deep abdominal areas, such as during repairs and are similar to a Jansen. Weitlaners may cardiothoracic surgery. They are also widely used in have sharp or blunt jaws and either an arrangement of general surgery. teeth that is 2 x 3 or 3 x 4.

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• Collier needle holders – hold medium-gauge needles. absorbable, non-metallic material • Brown needle holders – hold small-gauge needles to that minimizes tissue reaction apply sutures in superficial tissue (e.g., for plastic and infection. They may be surgery). preloaded on the stapling device. Staples are packaged in various Because needle holders must grasp metal rather than soft assortments of numbers and tissues, they are subject to greater damage than other types of staples, depending on the instruments. As a result, they must be carefully inspected and length of the incision, and the type of tissue to be stapled. repaired and replaced as needed. They are designed to Nonreactive metal staples will remain permanently in the withstand some amount of tension, but are not intended to be tissue. If staples must be removed, as with skin staples, an used as pliers. Always select a that matches the extractor is required. size needle being used and the depth of the surgical incision. Staplers are easy to use. Most employ a similar anvil type To load a needle on the needle holder, place the jaws near the mechanism for forming the staple, but they vary in terms of suture end of the needle, allowing about two-thirds of the point weight, handling characteristics, ease of application, and view of the needle free for passing through the structures to be of the site during application. They may fire individually or sewn. Load the needle so that the tip of the needle will point lay down multiple rows in a straight or circular pattern. to the surgeon’s thumb when the needle holder is passed. Devices to cut or anastomose bowel and other structures are When the surgeon receives it, the needle should be in position available for open wound use or through endoscopic cannula. and, ready to be passed directly into the tissue. If the surgeon is left-handed, load the needle in the needle holder in the Hemostatic clip appliers are small V-shaped staples that are opposite direction. used to occlude a vessel. These staples are usually placed one at a time with the use of a stainless steel instrument. The Needles should only be passed staples are hand loaded and passed to the surgeon who places hand-to-hand to the surgeon them around the vessel and then closes the applier to close the when absolutely necessary. staple. AORN’s Guidance Statement: Sharps Injury Prevention in the Accessory Instruments Perioperative Setting calls for In addition, there are accessory instruments that do not fit into the use of a “neutral or hands- any of these categories by nature of their function. These free technique whenever possible or practical instead of 2 include items such as suction tips, towel clips, probes, , passing hand-to-hand.” and ring forceps. If it is necessary to pass the needle holder to the surgeon, take Suction tips are used to remove blood and/or body fluids as care to prevent the suture from getting tangled or bunching up they accumulate to provide better ability to see the surgical in the surgeon’s hand. Pass the loaded needle holder into the site. Suction tips are available in different sizes and designs surgeon’s hand as you would pass any clamp, paying and may be provided as nondisposable or disposable. If particular attention to the direction of the needle. nondisposable suction tips are used it is very important that the lumens are cleared with a stylet and flushed when Staplers and hemostatic clip appliers processing. If the suction tip has multiple parts, the parts must Surgical stapling instruments are often used to suture tissue quickly. As surgeons have gained experience in the use of stapling devices, many different types have been developed to suture and resect tissue. They can come as a single-use device or a stainless steel instrument with disposable staple cartridges. Staplers are widely used in a variety of procedures that require ligation and division, anastomosis, resection, and skin and fascia closure. Skin staples have become one of the most frequently chosen methods of skin closure. These tiny surgical staples are made of stainless steel or an

12 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING be disassembled and sterilized separately and then re- coagulating capabilities. Endoscopic spatulas and hooks are assembled on the sterile field. The diameter of the suction routinely used with monopolar current, but virtually any type shaft determines the size. Narrow diameter suction tips are of dissector, blunt grasper, or scissors can be manufactured indicated for use in small delicate areas. Examples of suction with this option. The shafts of such instruments are insulated tips are Yankauer, Andrews, and Frazier. to avoid injury. This insulation must be carefully checked during processing and immediately before use to avoid patient Ruler, probes, and grooves are used to measure and to dilate injuries. and probe vessel lumens. Towel clips with sharp points are sometimes used with sterile cloth towels during the draping process. Once towel clips have been placed, they cannot be repositioned. Nonperforating towel clips are available that can be used to secure drapes and tubing. Mallets are hammer-like instruments used for striking objects like chisels or osteotomes. Speculums are used to hold open and provide access to an As with standard surgical instruments, it is important to be orifice (e.g., vagina, eye, nose). familiar with the anatomy of these specialized instruments. The identifiable parts are the: ENDOSCOPIC (MINIMALLY INVASIVE) • handle (can come in several different configurations, INSTRUMENTS controls the movement of the instrument), With the development and • locking mechanism (allows the instrument to be increase in endoscopic and secured in position), minimally invasive surgical • shaft (allows movement and rotation within the procedures, laparoscopic and endoscopic surgical field), and other minimally invasive instruments have been • tip (consists of the working end of the instrument and developed and are used may include a grasper, scissors, retractor, or routinely. Their functions electrosurgical devices). within a sealed peritoneal cavity are similar to traditional Endoscopes surgical instruments, but their care can be much different. Endoscopes may be rigid, Perioperative nurses need to be familiar with the specific semirigid, or flexible. Their lenses cleaning, disinfection, decontamination, and sterilization may allow various viewing angles. methods used for these types of instruments. Endoscopes are Diagnostic endoscopes are designed inserted into a body orifice or through a small incision to allow for observation only and have no surgeons to examine and operate in the interior body cavities, operating channels. Operative hollow organs, or other structures. endoscopes have a second channel All of the instruments used in endoscopic procedures must for irrigation, suction, and insertion and connection of other function through the narrow lumens of scopes and cannula instrumentation. They come in various diameters and lengths, that are often only 5 mm to 10 mm in diameter. Endoscopic depending on patient and procedural requirements. instruments typically have long shafts, with handles at the Endoscopic forceps and grasping instruments enable the proximal end to control the working tip at the distal end. surgeon to manipulate tissues. Endoscopic graspers have a locking mechanism to hold the tips firmly in place. Many of these instruments are single-use Trocars and cannulas When no natural orifice exists for insertion of a diagnostic or devices, but others are reusable and need specific cleaning operative endoscope, such openings can be created using a protocols. and cannula. The cannula is inserted into the operative Endoscopic Electrosurgical Instruments site using a sharp trocar as an obturator or by making a small Endoscopic electrosurgical instruments require special care surgical incision and inserting the cannula with a blunt-tipped and attention. These instruments provide cutting and obturator. Once the port of entry has been made, the trocar or

13 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING obturator is removed and the hollow tube cannula is left in appropriate instrument, the scrub person must understand place. what is taking place at the surgical site. Trocars and cannula may be disposable or reusable and come in several sizes. Those used for arthroscopy, for example, are much smaller than those used in the chest or abdomen. More than one size of trocar/cannula system may be required for a given procedure. If more than one size instrument will be inserted Sharp instruments should be through a given cannula. placed in a neutral zone from which the surgeon can pick up INSTRUMENT CARE AND HANDLING ON THE the instrument. Keep STERILE FIELD instruments free of gross soil by Each surgical procedure requires a specific set of instruments. wiping them with a moist Instrument sets may start with a basic or standard set of sponge and sterile distilled surgical instruments. Then special instruments are added that water. Instruments no longer meet the specialized needs of each procedure. needed for a procedure may be cleaned and immersed in a When setting up the sterile back basin of sterile, demineralized, table, the scrub person should distilled water. Flush any handle each instrument cannulated instruments with separately to prevent them from sterile water. Also flush suction interlocking which can cause tips and tubing with sterile damage. The scrub person water. 5 should also check each instrument for functional For a minimally invasive procedure, the same principles apply. readiness. Instruments should be laid side by side, avoiding The instrumentation may include a basic open setup as well piling them one on top of another. This prevents denting and as the required endoscopic instruments for the procedure. The nicking. Instruments such as scissors and forceps should be variety and configuration of the instrument setup will include checked for proper alignment of the tips and working order. the appropriate trocars and specialized instruments needed for Any damaged or defective instruments should be handed off the type of procedure being performed. Additional required the sterile field and marked for repair or replacement. Ring- video equipment should be available in the procedure room. handled instruments should be kept together with the box Attachments for powered surgical instruments should be locks closed on the first ratchet. The scrub person should point properly affixed to the units and tested before use. The scrub the curvatures and angles of person should place trigger clamps and scissors in the same handles in the safety position direction. Retractors and other when changing attachments or heavy instruments should be passing to the surgeon. If air laid out flat on the table. Sharp powered equipment is going to blades, edges, and tips should be used, the manufacturer’s be protected from touching written instructions should be other metal surfaces. followed for proper pressure It is important that the scrub person know the name and use settings. of each instrument as well as how to handle them. During Never rest powered surgical surgery, the scrub person is responsible for passing the correct instruments on the patient. If the instrument needed, handling instruments individually, keeping instrument is too large or instruments debris-free and clean, flushing suction tips and cumbersome to be placed on the tubing, and cleaning each instrument after use. To pass the back table when not in use,

14 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING prepare a separate sterile table or Mayo stand to hold it. This requires that items placed on top of a transport cart must be practice prevents serious injury to the patient from the weight contained (e.g., in a plastic bag). Blades and drill bits should of the instrument or from accidental activation. It also prevents be removed from powered equipment by the scrub person in the instrument from falling off the sterile field and avoids the procedure room before sending to the decontamination accidental contamination from saws and blades tearing area. Power equipment should not be immersed or placed through draping materials. under running water unless indicated in the manufacturer’s written instructions. INSTRUMENT CARE AFTER PROCEDURE Decontamination and cleaning may be done manually or After surgery, all instruments (used and unused) are automatically using detergent, water, and friction. The considered contaminated. To ensure that no instruments are manufacturer’s instructions should be followed for mixing of inadvertently discarded with the draping materials, instrument detergents as this can affect proper rinsing. counts must be finished and the sterile field must be checked before removing drapes. Refer to AORN’s Recommended Cleaning Practices for Prevention of Retained Surgical Items for 4 Separate from other instruments those instruments that are complete information about surgical counts. delicate, small, or have sharp or semi sharp edges and process Guidelines for instrument care them according to the manufacturer’s directions. Powered and and cleaning are essential and endoscopic instruments also should be handled separately. are based on manufacturer’s Instruments with removable parts should be disassembled to recommendations. When new, expose all surfaces. Reusable endoscopic or laparoscopic the instruments arrive packaged instruments need to be specially prepared before terminal with written guidelines, sterilization and use. Hinged instruments should be opened to booklets, and/or audiovisuals expose box locks and serrations. Instruments of dissimilar supplied by the manufacturer. metals should be separated to prevent the electrolytic These guidelines, when followed, direct perioperative and deposition of metals. sterile processing staff members on safe and effective methods As noted earlier, many surgical instruments are made of of cleaning, disinfecting, and sterilization and should always stainless steel. It should be noted that stainless steel is by be followed. The proper care and handling of valuable surgical nature, stainless, but it is not stain-proof. This is an important instruments will improve their longevity and function. consideration when subjecting stainless steel instruments to Cleaning protocols should be established and followed. The chemicals and detergents. perioperative nurse should ensure that instruments are cleaned, sterilized, handled, and used properly. Instrument washing takes place in the decontamination area of The process for the care and cleaning of instruments includes central processing. Proper attire several steps: decontamination, cleaning, inspecting, and personal protective lubricating and testing, packaging, and sterilizing. equipment must be worn by staff members in this area. The Decontamination purpose of cleaning is to remove The first step is decontamination. Decontamination renders residual blood and debris before instruments safe to handle. The decontamination and cleaning terminal sterilization. Some instruments require precleaning steps are often combined. by hand to remove gross debris before going into the washer, The decontamination process sterilizer, or decontaminator. Other instruments (e.g., delicate may begin in the procedure or complex ones) requiring disassembly, may need to be room with prerinsing and cleaned and dried by hand. presoaking. Presoaking When washing by hand, keep the instrument submerged to prevents blood and debris prevent microorganisms from splashing and aerosolizing. from drying on the Instruments with multiple parts should be disassembled and instrument. Instruments are box locks opened. Use a clean, warm water solution that is organized, contained, and noncorrosive and low-sudsing, and a prerinsing liquid transported to the central processing area using closed case detergent. Thoroughly rinse the instruments in deionized water. carts. The Occupational Safety and Health Administration

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An automated unit also can be used to mechanically clean and processed separately from other instruments. decontaminate instruments. These systems clean with cycles Endoscopes should be inspected before use. Scrub personnel that include a cold water prerinse to dissolve blood and should look for any scratches or dents, which might indicate a protein, a detergent wash, a rinse, and a final cycle of steam defect in the endoscope. No distortions should appear on the and heat. Instruments should be arranged in perforated trays, outside, or in the lens. If there is any moisture present or the placing heavy instruments in separate trays. If heavy and rod lens is damaged, cloudiness and possibly a loss of image lightweight instruments are combined in one tray, place the may result. Associated light cords and connectors also should heavier ones on the bottom and the smaller, lightweight ones be inspected to confirm that damage has not occurred during on top. Turn instruments with concave surfaces, such as processing. The light appearing through the cord should be curettes, so that the bowl side is down to promote drainage. even, without any darkened areas, which indicate broken Open box locks and pivots of hinged instruments to expose fibers. the maximum surface area. Separate instruments of dissimilar metals to prevent electrolysis, which can cause etching. Do Cleaning laparoscopic instruments not mix stainless steel instruments with other metals. Place Laparoscopic instruments can be challenging to clean. They sharp instruments in their own tray. Arrange instruments have evolved from first generation devices that were neatly, and do not randomly pile them on top of one another. extremely difficult to clean, to second generation devices that Avoid placing delicate instruments into the washer because include a cleaning port, to modern instrumentation which mechanical agitation may damage them. allows for complete disassembly for proper cleaning. Another type of automated method is the ultrasonic cleaner. After use and before the next surgical procedure, laparoscopic Ultrasonic energy uses high frequency sound waves to instruments must undergo several preprocessing steps, before thoroughly clean instruments by a process called cavitation. being cleaned, lubricated, and sterilized for reuse. It removes the tiniest particles of debris from serrations, box locks, and crevices of instruments that may be impossible to Preprocessing. The reprocessing of laparoscopic instruments clean by other methods. begins at point of use. As with all devices, excess body fluids and tissues must be removed immediately in the surgical suite. When pneumatic hand pieces are cleaned, the air hoses should be left attached. The outside of the hand piece should be wiped Several steps are necessary before laparoscopic instruments are with a detergent or germicide and dried. Hoses should be processed. Devices must be disassembled by carefully following inspected for damage or excess wear before and after the manufacturer’s written instructions because of the variability decontamination. Powered equipment and attachments should in how these instruments are designed (i.e., some models of be lubricated with a manufacturer’s recommended lubricant. laparoscopic instruments can be completely disassembled, some have flush ports, some have neither). The required cleaning Inspecting agents should be prepared according to the manufacturer’s use, Inspect and test the function of each instrument after dilution, and temperature recommendations. decontamination. They should all be clean, and those with Instruments should be inspected for any obvious insulation moveable parts should be lubricated according to the damage and bent or missing parts. If any insulation damage manufacturer’s directions. or missing parts are discovered, this should be reported Endoscope cleaning immediately for patient follow-up to assess whether the Endoscopes are fragile patient has been harmed. devices and require special Cleaning . Remember these basics when cleaning handling and care to prevent laparoscopic instruments: damage. To avoid fogging, • Manual cleaning is required for all instruments with the proximal end must be free lumens and hollow spaces. Automated cleaning with of moisture. The endoscope a washer/disinfector alone may not be effective. should be held by its housing body and/or eyepiece. Do not • Metal brushes or scratch/scouring pads should not be drop or shake the endoscope. When processing, endoscopes used on insulation because they damage the should never be placed in an ultrasonic cleaner as this will instrument’s surface and finish. Instead, use soft- damage the optics. Endoscopes should be cleaned and bristle, nylon brushes and cotton-tip swabs.

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• Use deionized or softened water, especially for the • Flush irrigation channels with deionized water and use final rinse. Note: Water with high mineral content (i.e., a stylus, if necessary, to remove clogs. If instruments hardness) can leave residues that affect performance. have cleaning ports, a Luer lock syringe filled with • Neutral pH enzymatic detergent cleaning agents are enzymatic solution can be attached to the cleaning port recommended. Alkaline detergents, if used, must be to flush the lumen. Note: Keep the distal end of the completely rinsed from the devices. Do not use lumen under water. If there are no cleaning ports, a corrosive fluids such as bleach-based products to three-inch piece of tubing can be inserted over the avoid damaging the instrument. distal tip, and a syringe can be attached to the tube’s opposite end for flushing. Compressed air can also be • Cold soak sterilization is not typically recommended used for flushing if a precise nozzle is available and if and, as is always necessary for all instrumentation, the the pressure can be controlled. Ultrasonic irrigators manufacturer’s instructions for specific devices should also are a useful way to flush instruments with lumens consistently be followed. to remove debris from hard-to-reach areas, and they • Totally immerse instruments during cleaning to can do so more effectively in a shorter time than a prevent aerosolization. Do not use steel wool, wire manual process. brushes, pipe cleaners, or abrasive detergents. • Some detergent solutions may leave a residue on the Anything other than high-quality brushes specifically gold electrical post connector surface that can cause designed for instrument cleaning may damage the occasional cord alarms. The residue can be removed device. with an alcohol-soaked swab rotated completely After disassembly, the following manual cleaning steps are around the gold connector surface. important: • Remove the device from the detergent solution and • All components should be immersed (i.e., soaked) in rinse thoroughly under running distilled or de-ionized a blood-dissolving, enzymatic solution prepared water for at least three minutes. according to the manufacturer’s instructions for at • Most instruments can be processed through a least five minutes with gentle agitation. Note: Soak washer/disinfector after manual cleaning is complete longer if protein-containing material is present. It is using the instrument cycle. If this is done, assure that advisable to soak instruments vertically to reduce the no residue remains. possibility that air bubbles will form. Vertical soaking Remove excess moisture and allow the instrument to dry also enables the solution to enter, rise through, and exit before sterilizing. the device if the solution is sufficiently deep. • Remove the device from the enzyme solution, and Inspection rinse it thoroughly under running tap water for at least three minutes. • Immerse all components in a detergent solution prepared according to the manufacturer’s instructions and clean all surfaces. • Use a hand-held, soft bristled brush with a back-and- forth motion to brush all surfaces. Pay special attention to the cord connector, crevices, grooves, fittings, and joints. • While still submerged, use a soft-bristled brush with a gauge recommended by the manufacturer to clean inner lumen surfaces. If a recommendation is not made, select a brush with soft bristles that are slightly Laparoscopic instrument insulation is susceptible to pin holes, larger in diameter than the actual lumen. Use complete cracks, tears, and overall loosening. These defects must be strokes and ensure that the bristles exit the lumen. discovered as the instruments are assembled before Push and pull the brush completely through the lumen sterilization to reduce the risk of electricity escaping through several times. If necessary, repeat the brushing process insulation failure points and to minimize the risk of by entering the opposite end of the lumen.

17 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING inadvertent patient burns. Patient infections, extended powered instruments may not be immersed in water. recovery times, and the need for a possible return to surgery Guidelines for cleaning powered equipment are to: may result from these burns. If defects are observed, a process • leave air hoses attached to the hand pieces should be in place for patient follow-up to determine if the insulation failure occurred during the last surgical procedure • use manufacturer-recommended detergents and injured the patient. To inspect the insulation, locate the • rinse all traces of detergent solution metal collar at the distal tip. The insulation should fit tightly • wipe air hoses clean with damp cloths against the collar with no spaces visible. Next, grip the • remove excess water insulation, and try to slide it back. If the insulation slides (i.e., moves), the instrument needs repair. Finally, check the • dry the outside of the equipment with lint-free towels instrument shaft for insulation cuts, cracks, and nicks and For battery-operated power tools, the batteries should be inspect the handle for chips or cracks because these defects removed and processed according to manufacturer’s indicate the need for repair or replacement. Some facilities recommendations. have insulation failure testers that are used routinely on all insulated instruments. Packaging The next step in preparing surgical instruments for future Powered Surgical Instruments procedures is packaging. Instruments must be thoroughly Powered instruments use nitrogen, compressed air, electricity, dried and lubricated as necessary before packaging. or batteries to be operational. Powered instruments are Instruments are arranged to prevent air and moisture from available for use in many different surgical specialties. Their being trapped and/or retained. Important concepts to use enables the surgeon to work more quickly and efficiently, remember are to: decreases surgical time and causes less trauma to tissues and • place instruments in a container that is large enough surrounding structures. Powered systems to evenly distribute metal mass in a single layer are complex and have varied assemblies of gears, rotating shafts, seals, and other diverse components. Most, however, • if steam sterilization is used, instruments with concave have the following basic parts: surfaces should be placed on edge to facilitate drying • hinged instruments should be opened and unlocked • A power source, which may be compressed gas, alternating current (AC), or direct current (DC) • instruments with removable parts should be disassembled • A hose or cord that connects the power source to the handpiece (AC and pneumatically powered • delicate and sharp instruments should be protected instruments only) with loose-fitting tip protectors that have been validated for use with the selected sterilization method • The handpiece itself • heavy instruments should be placed on the bottom of • Hand- or foot-operated controls the tray • Accessory attachments • use only validated containment devices to organize or The action of a powered surgical instrument may be facilitated separate instruments by attachment of a blade, drill bit, reamer, or bur to achieve • flush suction tip lumens and other channeled devices reshaping, removal, pinning, reaming, or carving of bone. with softened or deionized water before steam Power saws have either a reciprocating or oscillating action, sterilization while power operate via rotary action. The rotary action may be fast such as when drilling a hole for pin placement, or • remove stylets from lumens slower as when used for • line the instrument tray or basket with an absorbent, reaming the shaft of a long lint-free surgical towel as needed bone. Powered equipment should be disassembled before being When cleaning powered packaged for sterilization. Delicate parts should be protected instruments, make sure that and air hoses loosely coiled. Regardless of what sterilization the cleaning methods chosen method will be used, instruments must be packaged to allow follow the manufacturer’s the sterilizing agent to directly contact all surfaces. Steam written instructions. Many sterilization under pressure is the recommended method for

18 SURGICAL INSTRUMENTATION : U SE , C ARE AND HANDLING all instruments when possible. Steam makes direct contact gloves should be worn when cleaning instruments and with all surfaces, and water condensate revaporizes producing equipment. Hands should be washed after removing gloves as a dry, sterile instrument. perforations can occur in gloves and provide an avenue for contamination. The Occupational Safety and Health Sterilization Administration requires that a hepatitis B vaccination be The final step in preparing instruments for future use is offered to all employees at risk for exposure to blood-borne sterilization. There are multiple methods of sterilization or pathogens. high-level disinfection that can be used. The process chosen must be compatible with the type of instrument and the SUMMARY packaging material chosen. Please refer to AORN’s The perioperative nurse must ensure that surgical instruments recommended practices for complete information about 6 are selected based on their intended use and that they are sterilization methods. Also available is the video inspected, maintained, and sterilized adequately. Properly “Sterilization in the Perioperative Setting” from the AORN functioning tools are essential for performing surgical Perioperative Nursing Library. procedures and for the safe care and well-being of patients. SPECIAL PRECAUTIONS Ophthalmic Instruments Special precautions must be taken when reprocessing ophthalmic surgical instruments to reduce the risk of patient injury from toxic anterior segment syndrome (TASS). Most reported cases of TASS appear to be the result of inadequate instrument cleaning and sterilization. 6 Special precautions should also be taken when cleaning robotic instruments because these instruments have lumens with complex and difficult-to-clean internal and external components, both. Lumens and internal components should be flushed with compressed air after cleaning to prevent subsequent microbial growth.

Prion Diseases Special considerations should also be taken to minimize the risk of transmitting prion diseases. Prion diseases are thought to be transmitted through direct inoculation (e.g., oral ingestion, inoculation of scratched skin) and iatrogenically transmitted through transplanted contaminated tissue (e.g., cornea, dura mater). Prions are resistant to chemical disinfection and routine sterilization methods. Patients should be screened for the possibility of exposure to prion diseases and consideration should be given to what instruments will be used on patients suspected of having prion disease because of the extreme difficulty in sterilization of reusable 5 instruments.

Personal Protective Equipment (PPE) Personnel handing contaminated instruments and equipment must wear appropriate PPE consistent with the anticipated exposure. Personnel should expect splashes, splatters, and skin contact to occur during the processing of contaminated instruments. A fluid-resistant gown, heavy-duty gloves, and a mask and face protection are required PPE. Two pairs of

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REFERENCES

SURGICAL INSTRUMENTATION: USE, CARE AND HANDLING

1. NM Phillips, ed. Berry & Kohn’s Operating Room Technique. 11 th ed. St. Louis, MO: Mosby-Elsevier; 2007: 325, 328. 2. AORN guidance statement: sharps injury prevention in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 711-716. 3. Gruendemann BJ, Fernsebner B, eds. Comprehensive Perioperative Nursing. Volume 2: Practice. Boston, MA: Jones and Bartlett; 1995. 4. Recommended practices for prevention of retained surgical items. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 313-332. 5. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 513-536. 6. AORN’s recommended practices for sterilization in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012. 547-569 . 7. AORN. Sterilization in the Perioperative Setting [video]. Woodbury, CT: Cine-Med, Inc; 2010.

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POST-TEST SURGICAL INSTRUMENTATION: USE, CARE AND HANDLING Multiple choice. Please choose the word or phrase that best completes the following statements.

1) Compared to conventional hand-held instruments, 7) When decontaminating and cleaning a powered surgical instruments: pneumatically powered surgical instrument: a) enable the surgeon to work more quickly a) the gas hose should remain attached to the b) cause less trauma to surrounding tissues handpiece c) decrease surgical time b) a detergent/disinfectant solution should be d) all of the above used c) the outside should be dried with lint free 2) Powered surgical instruments are used for all of towels the following except: d) all of the above a) cutting and fixation of bone b) splitting the sternum 8) When packaging powered surgical instruments for c) harvesting of skin for grafting sterilization, small, delicate parts should be: d) suturing of tissue a) protected by placing in appropriate section of container or packaged separately 3) All of the following have a rotary action except: b) left unpackaged a) femoral reamers c) placed under the instrument to prevent b) automatic screwdrivers movement during sterilization c) bone rasps d) placed loosely in the container to prevent d) k-wire drivers stress and tension on the parts 4) Direct current is the source of power for: 9) A hemostat is classified as a ______a) pneumatic instruments instrument. b) battery-operated instruments a) cutting c) instruments that plug into wall current b) clamping d) all of the above c) grasper 5) When regulating the gas flow for pneumatic d) retractor instruments, the correct pressure (PSI) should be 10) When passing sharps during a surgical procedure, set: the best way to protect all members of the a) by the manufacturer surgical team is to use b) before the instrument is activated a) extra care c) while the instrument is activated b) an assistive device d) before attaching the hose c) a neutral zone 6) When not in use, powered surgical instruments d) a knife handle should be placed: 11) Curved Mayo scissors are usually used to cut a) on the patient a) delicate tissues b) on a nonsterile table b) heavier tissues c) on a separate sterile table or Mayo stand c) suture d) any of the above d) any of the above.

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12) A biting instrument used for cutting tough tissue or 20) The hemostatic clamp used to control superficial bone is called a(n) bleeders and to handle delicate tissue in plastic a) surgery and hand surgery is called a(n): b) rasp a) Oschner clamp c) osteotome b) Kocher clamp d) c) Mosquito clamp d) Peon clamp 13) The portion of a hemostat that runs from the finger rings to the box lock is called the 21) Which of the following is used to create an opening a) jaw in an operative site for ? b) ratchet a) cannula c) joint b) trocar and cannula d) shank c) scalpel with a #10 blade d) tissue scissors 14) A popular type of occluding clamp that has no teeth is the 22) Surgical instruments are crafted for intended a) Babcock clamp surgical purposes. Each instrument is designed to do b) one of the following: cut, grasp, occlude, expose, c) Kocher clamp retract, aspirate, and suture. d) Ochsner clamp a) true b) false 15) Sponge forceps are used for a) retraction 23) The perioperative nurse is precepting a new scrub b) absorbing blood in the operative field person. The scrub person picks up a disposable c) blunt dissection of soft tissue scalpel blade with gloved fingers and is attempting d) all of the above to attach it to the reusable scalpel handle. What is the most important skill the perioperative nurse 16) Compared to hemostats, needle holders have should teach the new scrub person? a) shorter, stubbier jaws a) Continue to use fingers to attach the blade since b) longer jaws fingers are more dexterous c) more teeth b) Lay the blade on the Mayo stand and slide the d) no ratchets handle onto the blade 17) The depth of the surgical site will help determine c) Hold the blade in a clamp or needle holder and a) the number of teeth on the instruments used advance it onto the handle b) the length of the instruments used d) Convince the OR to purchase disposable c) the number of instruments required scalpels only d) all of the above 24) The most common type of clamping instrument is a 18) Flat metal retractors that may be shaped or bent by hemostat. Non-crushing hemostats are designed to the surgeon at the field are called occlude which of the following: a) Army-Navy retractors a) bronchus b) Richardson retractors b) esophagus c) malleable ribbon retractors c) blood vessels d) Volkmann retractors d) trachea 19) The abdominal wall may be held open by a self- retaining retractor called a a) Balfour retractor b) Weitlaner retractor c) Jansen retractor d) Richardson retractor

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25) The surgical team is ready to close the surgical wound and has requested specific suture material. What instrument will the scrub person use to deliver the suture to the surgical team? a) needle holder b) hemostat c) Kocher d) thumb forcep 26) The identifiable parts of a clamp or forceps are: a) point and jaws b) box lock and shank c) finger rings and ratchet d) all of the above 27) Surgical instruments must be made of metal alloys that will resist corrosion. Exposure to which of the following will result in corrosion: a) sterilization methods b) cleaning solutions c) blood or body fluids d) all of the above

28) The scrub person must know the name and intended use of each instrument. As part of the surgical team the scrub person should: a) keep several clamps in hand at once b) not worry about cleaning since the instruments will continue to get dirty c) discard the suctions when they become clogged d) pass the instrument appropriately and for the intended use 29) When preparing a tray for the washer, it is acceptable to randomly place instruments and retractors in the tray as long as all areas are exposed to the cleaning process. a) true b) false 30) The instruments are being assembled for sterilization in their respective trays. Some of the retractors still have visible blood on them. These retractors should be: a) wiped off with a wet towel and placed with the others b) assembled anyway, the sterilizer will destroy any bacteria c) left out of the tray d) none of the above

23

4 2

1d 2d 3c 4b 5c 6c 7d 8a 9b 10 c 11 b 12 a 13 d 14 a 15 d 16 a 17 b 18 c 19 a 20 c 21 b 22 a 23 c 24 c 25 a 26 d 27 d 28 d 29 b

30 d

G N I L D N A H D N A E R A C , E S U : N O I T A T N E M U R T S N I L A C I G R U S

S R E W S N A T S E T - T S O P

H C , U : I S G N I L D N A D N A E R A E S N O I T A T N E M U R T S N L A C I G R U